Non-Traumatic Neck Pain

Common and potentially life threatening causes:

• Acute wry neck / torticollis
• Spondylosis
• Disc impingement
• Spinal stenosis
• Meningitis

Uncommon but life threatening causes:

• Pharyngitis
• Infective disciitis
• Spinal osteomyelitis
• Metastases

Risk stratification

The emergency clinician will frequently be presented with patients with neck pain without a history of trauma. Most will have simple conditions, such as spondylosis and do not pose a diagnostic challenge, nor will they need imaging. When neurological involvement occurs, imaging is required. High risk patients are those with insidious onset of symptoms, especially when other significant co-morbidities exist such as diabetes, mellitus and immuno-suppression.

Related Pathophysiology

Radiculopathy

Referred pain into the upper extremities often accompanies neck pain. Referred pain can be the initial symptom of a compressed nerve root by a ruptured disc or stenosis at the foramina from osteophytes. Radicular pain is usually described as sharp or even shock-like, and may be associated with certain activities or positions. The distribution of the pain usually follows dermatomes. Sensory changes are also often seen, with complaints of tingling and numbness being very common. On examination decreased sensation is found in a dermatomal pattern. Motor weakness may also be seen. Muscle innervation is more constant and has less overlap than sensory innervation and is better at predicting level of pathology. Motor deficits that are of a more long-standing nature can be associated with significant wasting. Hyporeflexia in the appropriate distribution is also seen.

Cervical radiculopathy can present acutely, as with a traumatic ruptured disc, or can be of a more chronic and intermittent nature, as is seen in foraminal narrowing from osteophytes. Typically, the inferior nerve root is affected (e.g. C5-6 disc abnormalities affect the C6 nerve root). C5-6 and C6-7 are the most commonly affected segments. A C5 radiculopathy typically presents with pain in the shoulder and the upper part of the lateral arm. Paresthesia is often seen in the more distal part of the affected dermatome. Deltoid weakness is seen commonly with a C5 radiculopathy. Biceps or brachioradialis weakness can be seen with a C6 radiculopathy along with the appropriate hyporeflexia. Paresthesias and frank sensory loss are more distal, and can extend into the hand. Root compression at C7 produces triceps weakness and a decreased triceps reflex. Pain extending into the distal forearm or hand is common. Sensory loss is commonly seen in the hand. The natural history of cervical radiculopathy is improvement with time in many patients.

Learning Bite

Key features in radiculopathy are spontaneous pain, clear dermatomal involvement and slow, spontaneous recovery.

Cervical radiculitis from a soft disc herniation may be less likely to improve spontaneously as that due to osteophytes. Non-surgical therapy can include oral or epidural steroids, cervical traction, physical therapy, bracing, and many others. In carefully selected patients with radicular symptoms and evidence of nerve root compression on their imaging studies, the majority can expect a favourable outcome with careful surgical management.

Myelopathy

Myelopathy is the clinical presentation of pathology affecting spinal cord function. The differential diagnosis for causes of myelopathy is large and includes trauma, metabolic, degenerative, inflammatory, toxic, infectious, and neoplastic aetiologies. Degenerative conditions of the spine may produce the symptoms of myelopathy. In many instances the onset of the myelopathy is insidious, and symptoms and signs subtle. Longstanding myelopathy, unfortunately, is rarely reversible. Early identification of patients with progression of myelopathy is essential to prevent permanent loss of neurologic function. Therefore, in patients who present with neck or thoracic spine pain, the history and physical exam should be tailored to exclude myelopathy. The most general signs of myelopathy are those of upper motor neuron dysfunction. Subtle symptoms include difficulty with fine motor control of the hands and fingers, gait problems and instability, and numbness. Hyperreflexia, increased tone, and weakness are the hallmarks of the clinical exam.

Degenerative disease may lead to an acute onset of myelopathy. Acute disc herniation may occur without significant injury. Patients who present with the acute onset of myelopathic symptoms need urgent evaluation with MRI or myelography. If pathology such as an acutely ruptured disc causing spinal cord compression is found, surgical evaluation should be sought. Acute worsening of cervical myelopathy in the setting of cervical stenosis can be seen in the face of fairly minor trauma. In patients with acute myelopathy without obvious fracture, but significant degenerative disease, cervical stenosis should be suspected.

Progression of the myelopathy can be very slow and gradual, or stepwise. It is not uncommon for the onset to be so insidious that patients are quite disabled before they seek medical evaluation for their symptoms. Careful history and examination can direct the level of suspicion. In patients with chronic myelopathy an MRI is the study of choice to evaluate the spinal canal. In patients who are unable to have an MRI, myelography and CT myelography is adequate and gives good information about the spinal canal.

Learning Bite

Myelopathy has an insidious onset, is rarely reversible, and must be investigated using MR.

History

This should include timing of the onset of symptoms. Non-traumatic neck pain is always of concern, and the covert causes must be considered, including meningitis, spinal infection and metastatic deposits within the spine.

In general, the following should be regarded as red flags in spontaneous neck pain:

• Presentation in patients less than 20 or over 55 years of age
• Constant, progressive pain
• Past history of carcinoma
• Systemic steroids
• Drug abuse, HIV
• Systemically unwell
• Weight loss
• Persisting severe restriction of cervical flexion
• Inflammatory disorders such as ankylosing spondylitis and rheumatoid disease

Examination

In a walking patient, follow the trusted approach: Look, Feel, Move, before imaging. Specific aspects are covered in the discription of conditions that follow:

1. Acute wry neck / torticollis

This commonly affects adolescents and young adults. The patient presents with the neck held at an angle, in constant pain. The pain experienced tends to be localized to the mid cervical region and is unilateral away from the direction of the deformity. The patient often describes a history of a sudden unguarded movement of the neck which causes sudden pain and restricted neck movement. There is normally no history of trauma. Treatment is expectant, and NSAID together with heat help to ease it.

The pathology causing this type of problem is debatable. There are two theories; nipped or trapped synovium, or alternatively mechanical sticking of roughened and irregular surfaces1.

2. Spondylosis

This is extremely common in the over 50s, and usually causes no significant symptoms. Minor injury, such as a missed step, can cause an exacerbation resulting in pain, which appears disproportionate to the trivial injury. Radiographic features are osteophytic lipping and narrowed disc space, as seen at C6/C7 on this film.

Learning Bite

Spondylosis is one of the most common causes of radicular symtoms in non-traumatic neck pain.

3. Disc impingement

In cervical disc prolapse part of the nucleus pulposus may protrude through the annulus fibrosus at its weakest part, most commonly posterolateral. A slight protrusion bulges against the posterior longitudinal ligament and causes localized neck pain but if larger then it may impinge upon the spinal nerve root at that level or upon the spinal cord itself. This type of condition may occur in the younger population due to injury or it can occur as a result of degeneration and cervical spondylosis. When pain is severe and unremitting, associated with clear radicular features, suspect disc impingement.

Neck pain associated with degenerative disc disease and osteophytes will improve in the majority of people without invasive treatment; although there is certainly a group that will go on to have chronic symptoms.

4. Spinal stenosis

Cervical stenosis results in myelopathy. It usually progresses slowly, and can be quite subtle in the early stages. The most common presenting complaints include neck pain, gait difficulties, and hand numbness and clumsiness. Loss of bowel and bladder control is uncommon early in the process. Occasionally patients will present with acute and profound spinal cord dysfunction after a hyperextension injury. More common is a stepwise decline in spinal cord function.

The typical patient with cervical stenosis is older than 50 and male. Men are seen nearly twice as often as women. Myelopathic findings dominate the physical findings. Increased reflexes in both the upper and lower extremities with lower extremity spasticity are common. Abnormal reflexes such as Babinski and Hoffman are also often present. Lhermittes sign (electric, shock-like pain radiating down the spine on neck flexion) is classically described, but occurs in a small minority of patients. Complicating the clinical picture is the lower motor neuron findings that can be seen secondary to nerve root compression, such as wasting, fasciculations, and hypoactive reflexes.
The differential diagnosis includes multiple sclerosis, syringomyelia, spinal cord tumor, subacute combined degeneration, and normal pressure hydrocephalus.

Learning Bite

Males over 50 with neck pain, muscle fasciculation and wasting should alert the clinician to the possibility of spinal stenosis.

Surgical decompression of the cervical spinal cord is recommended in the setting of any signs of myelopathy and significant cervical canal stenosis. Deficits acquired are rarely completely corrected by surgery, so most surgeons will tend to offer decompression as early as possible. In patients with significant cervical stenosis without signs or symptoms of myelopathy, operative indications are less clear.

5. Meningitis

Be vigilant for the neck pain of meningitis, which often creates a typical board rigidity of the neck. A patient with spontaneous neck pain who cannot kiss their knees is a candidate. Fever will usually be present, in a very unwell patient, with possible photophobia and headache. However, the time course is acute.

6. Pharyngitis

Neck pain may occur in pharyngitis, particularly when caused by certain viruses. As viral pathology is a common pathology in childhood, the neck pain may be over-emphasised, resulting in a misleading diagnosis. It has a peak occurrence in late summer. Distinctive clinical syndromes include acute lymphonodular pharyngitis caused by coxsackievirus A10, and hand-foot-and-mouth disease caused by coxsackievirus A5, 9, 10, and 16, and enterovirus 71.

A rare but life-threatening cause of pharyngitis in young adults is Lemierres syndrome. This condition is usually caused by the anaerobic bacterium, Fusobacterium necrophorum, and is characterized by a oropharyngeal infection with evidence of septic thrombophlebitis. The incidence is very low, but it should be considered when a critically ill patient presents with pharyngitis2. Metronidazole and clindamycin are effective in combination as first line treatment.

Learning Bite

Lemierres syndrome causes severe pharyngitis resulting in critical illness with septic thrombophlebitis.

Peritonsillar abscesses is a potent cause of neck pain, but is usually associated with ipsi-lateral ear pain, and obvious swallowing difficulty. It usually progress from tonsillitis to cellulitis and ultimately to abscess formation. Most recently, Webers glands have been thought to play a key role in the development of the infection. These mucous salivary glands are located superior to the tonsil in the soft palate and clear the tonsillar area of debris. If these glands become inflamed, local cellulitis develops. As the infection progresses, inflammation worsens and results in tissue necrosis and pus formation, most commonly just above the superior pole of the tonsil where the glands are located

Ludwigs angina is a serious, potentially life-threatening infection of the tissues of the floor of the mouth, usually occurring in adults with concomitant dental infections. It is named after the German physician, Wilhelm Friedrich von Ludwig who first described this condition in 1836. The cause is usually a bacterial infection, most often Streptococcal, although other bacteria can also cause this. The route of infection in most cases is from infected lower third molars or from an infection of the gums surrounding the partially erupted lower third molars. Although the wide-spread involvement seen in Ludwigs is usually seen to develop in persons with a state of lowered immunity, it can develop in otherwise healthy individuals also.

7. Infective disciitis and spinal osteomyelitis

Infective disciitis may occur in the immuno-compromised, often an intravenous drug user. It usually results in fever, and may progress to lytic collapse of the vertebral body (as shown), with consequent catastrophic quadraplegia. The onset is usually insidious, making it difficult to diagnose in the ED. A distant focus of infection may provide an infective nidus from which bacteria spread by the bloodstream to the spinal column. The skin and the genitourinary tract are common antecedent sites, but there may be multiple foci. Typically, the organism most likely to infect the spine is Staphylococcus aureus; however, in intravenous drug users, Pseudomonas species are also a common cause.

Intravenous drug abuse is a growing cause of spinal infections in UK ED practice. Nonpyogenic osteomyelitis can be caused by tuberculosis, fungus, yeast, or parasitic organisms

Approximately 30-70% of patients with vertebral osteomyelitis have no obvious prior infection3.
Risk factors for developing osteomyelitis include conditions that compromise the immune system, such as the following:

• Advanced age 4
• Intravenous drug use5
• Congenital immunodepression
• Long-term systemic administration of steroids
• Diabetes mellitus 6
• Organ transplantation
• Malnutrition
• Cancer

In a series of 14 cases of cervical osteomyletis over 4 years in Detroit, all were in iv heroin users7. While bacteraemia may be the main vector, it is also possible that direct infection from misplaced jugular injection may be the mode of infection. Similarly, ascending infection along the psoas sheath has been implicated in lumber disciitis and osteomyelitis in intravenous drug users.

Early investigation with xrays may show no defect, but the ESR and CRP are likely to be raised, and a bone scintigraphy is likely to be abnormal8.

Learning Bite

Repeated presentations in a patient injecting opiates, with neck pain and fever should alert the clinician to the possibility of cervical disc or vertebral infection. Inflammatory markers and bone scintigraphy may reveal the condition at an early stage

8. Metastases

Metastatic deposits create a similar radiological appearance to the lytic appearances of infection, and in many cases are completely covert ie there is no known history of carcinoma.

Diagnostics

Plain radiograph

Where plain radiography is indicated, three films are taken of the cervical spine: lateral, AP (anteroposterior) and open mouth (peg) views. This combination allows for good visualisation of the entire cervical spine. The x-rays can be interpreted using the ABCD system.

Adequacy/Alignment

The entire cervical spine should be visible from the occipital condyles to the top of T1 vertebral body. Sometimes the initial x-rays do not fully visualise the cervical spine. In these circumstances, there will be local variances as to how to progress. Initially, repeating the films with someone pulling caudally on the arms may suffice, but it may be necessary to take different views before proceeding to CT if images are still inadequate. The most common views taken are Swimmers view and oblique views.

You should also ensure that there is adequate exposure of the spinous processes and the soft tissues anterior to the vertebral bodies.
Four lines should be drawn:

1. Anterior aspect of the vertebral body this marks the line of the anterior longitudinal ligament
2. Posterior aspect of the vertebral body this marks the line of the posterior longitudinal ligament and is the anterior limit of the spinal canal
3. Spino-laminar line the junction of the laminae and the spinous processes. This is also the posterior limit of the spinal canal
4. Spinous process line

Bones

Each bone should be fully assessed for injury or structural abnormalities. The odointoid process, in particular, should be scrutinised for fractures. These occur most commonly at the base.

Be aware of the possibility of Mach effect resembling a fracture (first image). This effect occurs when superimposition of normal structures give the appearances of a fracture. Most typically, this occurs when the base of the skull gives the appearance of an odontoid base fracture. Work around the outline of the odontoid process. The second image shows a peg fracture. Next assess the body of C2, then assess the integrity of C1. There should be no more than 12mm between a line drawn from the tip of the basion (anterior edge of foramen magnum) to the tip of the dens

The body of C2 should have a visible ring on the lateral view the Harris ring, as shown9. This may be incomplete between the 5 and 7 oclock position in the normal x-ray. However, if there is disruption elsewhere, then this should raise suspicion for a fracture.

Cartilage

Although cartilage itself is not visible on plain imaging, the cartilaginous spaces should be assessed for uniformity. Special note should be made of the following:

• The distance between the vertebral bodies from C2/3 onwards. This should be similar at all levels.
• The C1/2 articulation. The distance between the anterior margin of the odontoid process and the posterior portion of the arch of C1 should be no greater than 3mm in the adult spine.
• The facet joints. Assess for uniformity at each level.

There should be uniformity of the distance between the odontoid process and the ring of C1. Asymmetry may occur secondary to rotation, but the lateral masses should be closely inspected for any mal-alignment.

Dense soft tissues

The paravertebral soft tissues should be examined for any oedema or haematoma. The soft tissue between the larynx and the spine should be examined for swelling or distortion, indicating the possibility of infection, or an underlying fracture. In flexion, there may be an apparent increase in the soft tissue anterior to C1 and C2. This may be most marked in young children due to the laxity of the soft tissues in this age group and in some cases due to crying.

Variations in paediatric patients:

• Relatively large head leading to higher fulcrum of flexion (C2/3)
• Horizontally aligned facet joints
• Underdeveloped uncinate process leading to flatter articular surface
• Anterior wedging of vertebral bodies
• Cartilaginous synchondrosis at the junction of the odontoid peg and C2 vertebral body
• Less rigid ligamentous support and weak supportive muscles

CT imaging

Defects in the bony spine are seen well with CT, and therefore if bony lesions are suspected this is a good investigation. In spontaneous neck pain, therefore, if spondylitic change, the presence of metastases or osteomyelitis is being considered, CT is the preferred investigation.

In one series, CT and MR imaging were used in 325 positive diagnoses. CT missed 18 of these, but was preferable in the evaluation of meningioma and separation of tumour from oedema10. As CT takes less time it is preferable in very young or elderly individuals.

In this CT image, the spondylitic change at C6/C7 is clearly shown.

MRI scanning

In MRI scanning the spin and precession of hydrogen ion nuclei in the presence of a magnetic field become aligned, but this alignment will alter when they are subjected to radiofrequency pulses. As a consequence their energy level rises, but on withdrawal of the pulse, they return to their lower energy state and emit energy, which can be detected.

Different tissue types display differing emission patterns. In addition, the emission patterns can be influenced by differing patterns within the radiofrequency pulse.

These various patterns deliver weightings that can highlight materials with differing characteristics, e.g. water content, fat content.

• T1 weighting is characterised by an increased signal from fatty tissue and a lower signal from fluid, giving a more structural view. In particular, bony destruction or infiltration with loss of fatty tissue is highlighted.
• T2 weighting produces images containing deep muscle tones and bright fluid, and can be very helpful in spinal views. It is a particularly useful modality useful to investigate cord or disc lesions. Here is a normal T2 weighted cervical spine image.
• Diffusion weighted imaging uses the mobility of water molecules as a means of describing structure associated with impairment of molecular movement due to tissue characteristics. Increasingly, it is commonly used for the diagnosis of ischaemic stroke.

MRI can provide images in almost any plane, and is the imaging modality of choice in spinal cord disease. It can be facilitated by both T1 and T2 weighted protocols, depending on the structures under scrutiny. T2 weighting is particularly useful for visualising the cord and nerve roots, so highlighting any expanding lesion or impingement from adjacent structures. T1 images will yield more information concerning bone substance and marrow any destruction or infiltration being revealed by a reduced signal.

Here is a C3/C4 fracture with partial cord transection. It is a T2 weighted image.There is cord disruption at the C3/C4 joint (white arrow) and high signal of CSF (yellow arrow).

Myelography

Myelography consists of an injection of contrast medium into the cervical space with fluoroscopic guidance followed by xrays. It may help to find the cause of pain not found by an MRI or CT, but it has been largely replaced by the use of CT and MR scans.

A CT or MR may be performed after myelographic material has been placed. The material is typically water-based, which has replaced oil-based fluids. A CT myelogram is most useful for patients who cannot undergo MRI (eg those with pacemakers or cochlear implants) or for those in whom MRI provides limited information (eg those with extensive metal in the spine).

• Ensure adequate pain relief: combination analgesic therapies may be required
• Be sure to confidently diagnose the cause of spontaneous neck pain
• Seek a specialist opinion when an unusual case occurs

Physiotherapy

The aim of physiotherapy is to reduce pain, improve posture and improve the range of movement. Treatments often include the manual mobilization of joints segmentally in the cervical spine1.

• Failure to involve a senior in unusual or worrying cases
• Missing red flags in spontaneous pain
• Be very careful when a patient with insidious neck pain presents
• Be vigilant for disciitis, osteomyelitis and metastatic disease, all of which have the potential to cause quadraplegia if undiagnosed.

1. Timothy J, Foley E, Comer C, et al, Soft tissue series: 3. Paraspinal Emerg Med J 2008;25:514521
2. Lemierres syndrome, reemergence of a forgotten disease: a case report. Cases J. Mar 10 2009;2:6397
3. Mart nez Hern ndez PL, Amer L pez M, Zamora Vargas F, et al. Spontaneous Infectious Spondylodiscitis in an Internal Medicine Department: epidemiological and clinical study in 41 cases. Rev Clin Esp. Jul 2008;208(7):347-52.
4. Cahill DW, Love LC, Rechtine GR. Pyogenic osteomyelitis of the spine in the elderly. J Neurosurg. Jun 1991;74(6):878-86.
5. Gotway MB, Marder SR, Hanks DK. Thoracic complications of illicit drug use: an organ system approach. Radiographics. Oct 2002;22 Spec No:S119-35.
6. Toyota T. Vertebral osteomyelitis in diabetes mellitus. Intern Med. Jun 1997;36(6):382-3.
7. Endress C, Guyot D, Fata J et al Cervical Osteomyelitis due to IV heroin use: radiologic findings in 14 patients
8. Singh G, Shetty RR, Ravidass MJ, et al, Cervical osteomyelitis associated with intravenous drug use. EMJ (2006) 23(2) e16
9. Harris JH, Burke JT, Ray DD. et al. Low (type III) odointoid fractures: a new radiographic sign. Radiology, (1984) 153, pp. 353-356.152:695-702
10. Bradley WG, Waluch V, Yadley RA et al, Comparison of CT and MR in 400 patients with suspected disease of the brain and cervical spinal cord. Radiology September 1984